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<br />WHEN THUS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTFFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL C%D @I9f�E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIOG& n V"CH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE -
<br />MAR 2 0 2003 200509410 ~. _. REGISTRAR
<br />I�TAN�` STATE REG/SFRAR
<br />ASS
<br />LINCOLN, NEBRASKA HEALTH AND HUINAAFAMVICES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE ANaSUFN)RT
<br />VITAL STATISTICS - o �J 03226
<br />CERTIFICATE OF DEATH -
<br />t. DECEDENT - NAME FIRST MIDDLE LAST ;Male EX 3 DATE OF DEATH /Mnnrrr. Day.,Year /^
<br />r Lee A. Jacobson arch 19 4. C11Y AND STATE OF BIRTH fit not,n USA.. name country) 5a. AGE Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /Mont, Day. ye��ar' 5b MOS. DAYS HOURS' MINS. Maw 4 , l 9 60 mT
<br />Grand Island Nebraska 42
<br />z A 7. SOCIAL SECURTIV NUMBER 8a. PLACE OF DEATH
<br />HOSPITAL: ❑ Inpatient OTHFR ❑ Nw. ny 0,,r,e
<br />5 0 6- 6 6 - 5 4 5 3
<br />i v ❑
<br />EH Outpatient Residence
<br />ys 8b. FACILITY - Name lfl ro institution. give sheet and number)
<br />A
<br />2003 W. 11th Street ❑ DOA DlherlSpeC�fk,
<br />R EATH Be. INSIDE CITY LIMITS 8e. COUNTY OF DEATH
<br />Sc. CITY TOWN OR LOCATION OF D
<br />-Grand island Yes [n No ❑ IIall
<br />9a RESIDENCE - STATE 9b. COUNTY 9c. CI7 Y. TOWN OR LOCATION 9d STREET AND NUMBER hncludin9Zip Caiel 9p INSIDE CITY LIMOS
<br />A
<br />Nebraska Hall Grand Island 2003 W. 11th St. 58803 Yes Np
<br />O 10 RACE • le.g., White. Black. American Indian. 11, ANCESTRY (e.g.. Italian. Mexican, German, elcl 12. ® MARRIED El WIDOWED 13. NAME OF SPOUSE !If wile. give maiden name/
<br />etc.) lS yI (Specify) NEVER DIVORCED Core A. Sanders
<br />0" `finite Norwr ian FRI
<br />14a. USUAL OCCUPATION (Give kindpf work done during mast 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only highest grade completed) -
<br />of worknlg life, even Hretiredl Elemeryary or Secondary 10 -121 College 11.4 or 5•
<br />Welder A riculture Factor 1 -
<br />/6. FATHER -NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />m Helen M. Stahnke
<br />a, Ole L. Jacobson -
<br />16. WAS DECEASED EVER IN US. ARMED FORCES? 19a. INFORMANT
<br />18.
<br />NOno. or unk.l In yes. give war and dates of servicesl WIFE • Corey A. Jacobson
<br />tr 19b. INFORMANT MAILING ADDRESS ISTREET OR R.F.D. NO.. CIYV OR TOWN. STATE. ZIP(
<br />a2003 W. 11th Street Grand Island NE 68803
<br />20. EM8 SIGNATU LICENSE 21 a. METHOD OF �ISPO.IITION ib DATE 21c. CEMETERYOFICREMATORY NAME
<br />10$5 ❑Burial emoval r 19, 2003 Nebraska Anatomical
<br />CEMETERY OR CREMATORY LOCATION
<br />CITY OR TOWN STATE
<br />22a. FUNERAL HOME -NAME
<br />tr Nebraska Anatomical Board ❑Cremation' ®Donau"' Omaha Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE, ZIP(
<br />n 986395 Nebraska Medical Center Omaha, Nebraska 68198 -6395
<br />C 23. IMMEDIATE CAUSE
<br />(ENTER ONLY pNE CAUSE PER LINE FOR tort. lot. AND (cll I Interval between onset and deatb-
<br />1 PART a
<br />m r
<br />�j tort � G � I Interval bo en onset and Hearn
<br />DUE TO OR AS A CONSEQUENCE OF
<br />p I
<br />41r
<br />(b) .�.._- -_.... .. ..__
<br />Interval between Ansel and dea
<br />DUE TO. OR AS A CONSEQUENCE OF: I th
<br />PART III IF p I
<br />Ipl 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL
<br />OTHER SIGNIFICANT CONDITIONS • Conditions contributing to the death but not related PREGNANCY IN PAST 3 MONTHS" EXAMINER OR CORONER,
<br />PART
<br />�fy
<br />It (Ages 10.54) Yes No Vas Nu Ves tJp
<br />26a. 26b. DATE OF INJURY /Mo.. Day. Yr./ 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident Undetermined p 1?�g M - -
<br />Suicide Pending 26e. INJURY AT WORK 261. de buOilding�JRV PI h0T farm. street. factory 26g. LOCATION STREET OR R.F.D. NO CITY OR TOWN S7ATC
<br />Homicide Investigation Yes ❑ No ❑ pecify
<br />/M�. 28a. DATE SIGNED /Mo.. Day. YrJ 28b TIME Of! DEATH
<br />27a. DATE OF DEATH 0 Day. Yr.)
<br />a u 26c. PRONOUNCED DEAD (Mo. Day, Yr,) 26d. PRONOUNCED DEAD (Noun
<br />27b. DATE SIGNED (M°.. Day. YO 27c TIME OF DEATH c
<br />3 O., ©3 .20 A M -' M
<br />o g opinion death mcuned al
<br />270. To the best of my knowleege. de occurred at the time, date a p ce and due to the 28e. On the is a examination due to investigation, in my
<br />� s the time. date and place and due t0 the causels) stated,
<br />causelsl stated.
<br />► (SI nature and Titlel Op
<br />(Si nature and Title
<br />29. DID TOBACC SE CONTRIBU THE DEATH? 30.a HAS ORGAN OR TISSUE -OCMAT N BEEN CONSIDERED? 30.b WAS CONSENT GRANTED?
<br />VES ❑ NO ❑ U NOWN ES ❑ NO VES ❑ NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATYORNEYI /Type Or Print �7
<br />3rr Gr S /a aHall �f
<br />32b. DATE FILED BY REGISTRAR (All.. Day Ycl
<br />- 7 32. . REGISTIiA
<br />MAR 2 4 2003
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<br />WHEN THUS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTFFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL C%D @I9f�E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIOG& n V"CH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE -
<br />MAR 2 0 2003 200509410 ~. _. REGISTRAR
<br />I�TAN�` STATE REG/SFRAR
<br />ASS
<br />LINCOLN, NEBRASKA HEALTH AND HUINAAFAMVICES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE ANaSUFN)RT
<br />VITAL STATISTICS - o �J 03226
<br />CERTIFICATE OF DEATH -
<br />t. DECEDENT - NAME FIRST MIDDLE LAST ;Male EX 3 DATE OF DEATH /Mnnrrr. Day.,Year /^
<br />r Lee A. Jacobson arch 19 4. C11Y AND STATE OF BIRTH fit not,n USA.. name country) 5a. AGE Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /Mont, Day. ye��ar' 5b MOS. DAYS HOURS' MINS. Maw 4 , l 9 60 mT
<br />Grand Island Nebraska 42
<br />z A 7. SOCIAL SECURTIV NUMBER 8a. PLACE OF DEATH
<br />HOSPITAL: ❑ Inpatient OTHFR ❑ Nw. ny 0,,r,e
<br />5 0 6- 6 6 - 5 4 5 3
<br />i v ❑
<br />EH Outpatient Residence
<br />ys 8b. FACILITY - Name lfl ro institution. give sheet and number)
<br />A
<br />2003 W. 11th Street ❑ DOA DlherlSpeC�fk,
<br />R EATH Be. INSIDE CITY LIMITS 8e. COUNTY OF DEATH
<br />Sc. CITY TOWN OR LOCATION OF D
<br />-Grand island Yes [n No ❑ IIall
<br />9a RESIDENCE - STATE 9b. COUNTY 9c. CI7 Y. TOWN OR LOCATION 9d STREET AND NUMBER hncludin9Zip Caiel 9p INSIDE CITY LIMOS
<br />A
<br />Nebraska Hall Grand Island 2003 W. 11th St. 58803 Yes Np
<br />O 10 RACE • le.g., White. Black. American Indian. 11, ANCESTRY (e.g.. Italian. Mexican, German, elcl 12. ® MARRIED El WIDOWED 13. NAME OF SPOUSE !If wile. give maiden name/
<br />etc.) lS yI (Specify) NEVER DIVORCED Core A. Sanders
<br />0" `finite Norwr ian FRI
<br />14a. USUAL OCCUPATION (Give kindpf work done during mast 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only highest grade completed) -
<br />of worknlg life, even Hretiredl Elemeryary or Secondary 10 -121 College 11.4 or 5•
<br />Welder A riculture Factor 1 -
<br />/6. FATHER -NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />m Helen M. Stahnke
<br />a, Ole L. Jacobson -
<br />16. WAS DECEASED EVER IN US. ARMED FORCES? 19a. INFORMANT
<br />18.
<br />NOno. or unk.l In yes. give war and dates of servicesl WIFE • Corey A. Jacobson
<br />tr 19b. INFORMANT MAILING ADDRESS ISTREET OR R.F.D. NO.. CIYV OR TOWN. STATE. ZIP(
<br />a2003 W. 11th Street Grand Island NE 68803
<br />20. EM8 SIGNATU LICENSE 21 a. METHOD OF �ISPO.IITION ib DATE 21c. CEMETERYOFICREMATORY NAME
<br />10$5 ❑Burial emoval r 19, 2003 Nebraska Anatomical
<br />CEMETERY OR CREMATORY LOCATION
<br />CITY OR TOWN STATE
<br />22a. FUNERAL HOME -NAME
<br />tr Nebraska Anatomical Board ❑Cremation' ®Donau"' Omaha Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE, ZIP(
<br />n 986395 Nebraska Medical Center Omaha, Nebraska 68198 -6395
<br />C 23. IMMEDIATE CAUSE
<br />(ENTER ONLY pNE CAUSE PER LINE FOR tort. lot. AND (cll I Interval between onset and deatb-
<br />1 PART a
<br />m r
<br />�j tort � G � I Interval bo en onset and Hearn
<br />DUE TO OR AS A CONSEQUENCE OF
<br />p I
<br />41r
<br />(b) .�.._- -_.... .. ..__
<br />Interval between Ansel and dea
<br />DUE TO. OR AS A CONSEQUENCE OF: I th
<br />PART III IF p I
<br />Ipl 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL
<br />OTHER SIGNIFICANT CONDITIONS • Conditions contributing to the death but not related PREGNANCY IN PAST 3 MONTHS" EXAMINER OR CORONER,
<br />PART
<br />�fy
<br />It (Ages 10.54) Yes No Vas Nu Ves tJp
<br />26a. 26b. DATE OF INJURY /Mo.. Day. Yr./ 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident Undetermined p 1?�g M - -
<br />Suicide Pending 26e. INJURY AT WORK 261. de buOilding�JRV PI h0T farm. street. factory 26g. LOCATION STREET OR R.F.D. NO CITY OR TOWN S7ATC
<br />Homicide Investigation Yes ❑ No ❑ pecify
<br />/M�. 28a. DATE SIGNED /Mo.. Day. YrJ 28b TIME Of! DEATH
<br />27a. DATE OF DEATH 0 Day. Yr.)
<br />a u 26c. PRONOUNCED DEAD (Mo. Day, Yr,) 26d. PRONOUNCED DEAD (Noun
<br />27b. DATE SIGNED (M°.. Day. YO 27c TIME OF DEATH c
<br />3 O., ©3 .20 A M -' M
<br />o g opinion death mcuned al
<br />270. To the best of my knowleege. de occurred at the time, date a p ce and due to the 28e. On the is a examination due to investigation, in my
<br />� s the time. date and place and due t0 the causels) stated,
<br />causelsl stated.
<br />► (SI nature and Titlel Op
<br />(Si nature and Title
<br />29. DID TOBACC SE CONTRIBU THE DEATH? 30.a HAS ORGAN OR TISSUE -OCMAT N BEEN CONSIDERED? 30.b WAS CONSENT GRANTED?
<br />VES ❑ NO ❑ U NOWN ES ❑ NO VES ❑ NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATYORNEYI /Type Or Print �7
<br />3rr Gr S /a aHall �f
<br />32b. DATE FILED BY REGISTRAR (All.. Day Ycl
<br />- 7 32. . REGISTIiA
<br />MAR 2 4 2003
<br />
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